It's been a while

...and, I'm back.

I recently turned a corner in residency, being now a fifth-year "lab resident." That means that I'll have rare periods of clinical responsibilities, but otherwise will spend my time working on a variety of research projects, most of which will concern the care of spinal disease. I'll also resume 'normal' work hours for the most part, so I can say goodbye, hopefully, to the dark circles under my eyes and the twenty or so pounds of excess flesh I've lugged around with me for the past several years. Even more importantly, I can spend some time writing. Perhaps I'll even write on this blog.

A few issues these days really have me steamed, and most of them concern health care reform and health care bureaucracy (a word for which I harbor such an intense antipathy that my brain refuses to remember how to spell it, no matter how many times I look it up). Without going into specifics in this instance, I'll just highlight the fundamental problem, as I see it, with the creation and enactment of any truly beneficial reforms to our current system.

That problem, I think, is that people with little to no appreciation for the day-to-day challenges of taking care of patients are the ones making the decisions. We have career economists telling us how the finances of health care are to be managed; we have politicians and journalists (and economists) telling us that inevitable events can never happen, and if they do then it impugns our entire health care system; and we have pundits from both sides struggling to represent their own interests without anyone actually sitting down to, as my high school A.P. history teacher would say, "wrap their minds around the problem." President Obama, to his credit, is making an effort of sorts to listen to physician input. However, the whole of physician input cannot be encapsulated in a single New Yorker article written by an academic surgeon--particularly when that article highlights an instance of physicians providing "too much treatment" without making any sort of common-sense attempt to understand the generative forces that created that situation. (Though I'm tempted to go in for a David Foster Wallace-style endless footnote here, I'll just state parenthetically that perhaps the reason some physicians are becoming more entrepreneurial, inserting themselves into multiple revenue streams aside from simply seeing patients, is that physician reimbursements have been flat or declining for the past twenty years; and that when you have a segment of the most highly intelligent, educated, ambitious, and capable people in the population who feel they are not being reimbursed at a scale commensurate with their efforts and sacrifices, we shouldn't be surprised to find them getting their cookies from some other jar). Yet hear we are, facing perhaps the biggest legislative decision our country has faced in over fifty years, and we're doing it with a bunch of blind men as our guides.

My proposal would be as follows: create a think-tank of health care practitioners representing multiple sectors of the health care 'machine,' and charge them with the task of coming up with a solution to the health care crisis. Cloister them in a cabin in Montana, with a small library of books on health care policy, Medicare regulations, economics, political science, and history, along with detailed descriptions of how health care is provided in the twenty or so countries who seem to have found the greatest success with universal health care. DO NOT include in this think tank any career economists or politicians; instead, provide contact information for such people who can serve as consultants, should any questions arise that need immediate answers not available in the reference library. Finally, give this think-tank a deadline, say one month or so, to come up with a concise framework for health care provision in this country.

Why would this idea work? Well, because you'd have people who know what it's like to take care of patients coming up with solutions that respect patient care FIRST, and all other considerations secondarily. You'd also be entrusting the decision to people who have some skin in the game and who have to live with the end results, rather than to somebody who's going to sit back and criticize and condemn no matter the outcome.

So, anyways, that's my suggestion. We'll see if it garners the same reception around the White House as Atul Gawande's article did.

A long letter to the NY Times

I wrote a long reply to an opinion piece in the New York Times today, only to find that they had ceased accepting any further reader comments. In an attempt to have someone else in the world read this thing beside myself, I’ll post it here. The opinion piece in question can be found here.

* *

As a neurosurgical resident—someone immersed (and sometimes nearly drowning) in our health care system—I take issue with the contention that American health care is the “worst” or provides too little for too much expense. Sure, our system has pitiable faults: we insure far too few, our preventative care lags behind that of other countries, and we devote an onerous proportion of our nation’s GDP to medical care, among other problems. However, this country is the best place in the world to be if you’re sick—and by this I mean really, imminently-likely-to-die sick. We Americans believe in and practice the hail-mary pass, the last-ditch effort that fails most of the time, but every so often pulls off a miraculous victory. That’s a beautiful, unique thing, which you won’t find in the U.K. or Canada. It’s also quite expensive.

In addressing this issue of expense and quality, the authors propose that we somehow fix the health care situation by making health care more like pro sports. If that means I get paid like a pro baseball player, then hey, I’m all for it. Otherwise, I think we need to examine their flimsy analogy a little more closely.

The authors suggest that our medical care is hampered by our lack of data-driven methods. Well, when we examine the American health care system with respect to other countries, we’re actually doing fairly well. The U.S. is a world leader in advancing the cause of evidence-based medicine, and the effects of this trend have reached into every corner of the profession. Thanks to the prolific output of clinical trials, even a lowly medical student can contradict a medical professor if her point is backed with published evidence; this wouldn’t have happened twenty years ago. And I think we’re seeing the positives day-to-day, with more standardization of care and less therapy by doctor fiat. However, what we don’t see as evidence-based medicine becomes more widespread is a decrement in the cost of care.

The problem here is that, with respect to the cost issue, the authors demonstrate their own adherence to a hidebound rhetorical tradition: the logical fallacy of begging the question. They assume as a premise of their argument that evidence-based treatments will be less expensive than those based upon “informed opinion, personal observation, or tradition.” In reality, clinical studies are almost universally designed to demonstrate which therapy is more efficacious, not more economical. In all likelihood, further evidence-based trials will push us toward newer therapies that utilize more health care dollars, as these newer therapies are those that have proliferated in the “profligate” current age of medicine, rather than in earlier, more parsimonious times.

As for the question of quality, evidence-based medicine no doubt has its benefits, but it’s not the panacea the authors would suggest. Certain areas of medicine do not so easily lend themselves to clinical trials. In particular, surgical therapies hinge upon experience and tradition; one would be hard-pressed to create a study evaluating a new, alternative treatment of uncertain efficacy, as neither patients nor hospital research approval boards would be eager to turn away from an established, manifestly effective surgical technique. Suppose your loved one suffered a serious surgical illness; would you want her to receive the tried-and-true, “traditional” treatment strategy, or to be randomized into a study involving an experimental arm with an untested and quite possibly inferior therapy?

We also need to think about the issue of whether we really even want what evidence-based medicine can provide, especially with regard to that spectrum of care that approaches, at its extreme, futility. What if the evidence proves that, in a certain situation, it’s not wise, as illustrated by the data, to try to save your life or that of a loved one? Because, you see, in the author’s baseball analogy, that aging star player whose contract the data-driven team won’t renew corresponds to the aging, debilitated, or otherwise acutely ill person arriving in the emergency department. Should we care for him? Or would it be more cost effective just to let him die, to divert those hundreds of thousands of dollars to some other form of data-driven care rather than spending it on a “hidebound,” heroic effort that could very well save a life, albeit at tremendous expense? This may sound farfetched, but it’s exactly the sort of decision upon which cost-effective care in many industrialized countries is based.

The essence of prudence is sacrifice. I, for one, do not believe that we as a nation are willing to give up our heroic care.

In any case, I applaud the authors for wanting to improve our health care system. What they need to realize, though, is that the problem facing us is complex, and that evidence-based medicine is an important but fractional component of the approach we will have to employ to improve our health care system. To get there, though, we’ll need more than glib analogies and empty rhetoric.

By the way…as for the author’s proposed institute for evidence-based medicine—sounds great! Sign me up. Who, by the way, is writing the check?

Marathons and motivation

I've managed to squeeze a few hours of Olympics into my schedule in the past week, including much of the live broadcast of the marathon. Much hype surrounded this event in the American press, as one of our athletes--Ryan Hall--was considered a relative favorite to attain a medal. The New Yorker even ran a story about him, suggesting that he represented the changing of the guard in American distance running, with our country finally bringing to the Games a team capable of threatening the African nations for distance running dominance. [As a side note, not much recognition in that article was afforded to Meb Keflezighi, the American who brought home silver from the last Olympics; perhaps we Americans hesitated to claim an athlete with a decidedly African name?]

As I watched the marathon unfold, though, it became rapidly evident that the Kenyans and the Ethiopians would duke it out for the medals, while the American hopefuls would likely fade into double-digit placing (except for Dathan Ritzenhein, who graduated from my alma mater, finishing ninth). While I listened to the relatively strong commentary on the race, I pondered why it was that Americans continue to lag behind their African counterparts, when it seems increasingly that their training regimens and various other modifiable factors are indistinguishable from the Kenyans. Then, all of a sudden, one of the announcers provided me with an epiphany.

He described how Kenya has in recent months suffered tremendous civil strife following a controversial presidential election, resulting in what is essentially a civil war between the country's two major tribes. The Kenyan distance runners, then, came to these games with a great weight on their shoulders: because their country holds distance runners in such esteem, the team hoped that by bringing home a gold in the marathon--a feat which, bizarrely, the Kenyans have never been able to achieve despite their tremendous running prowess--they could help to alleviate the conflict in their nation and unite the two warring tribes. Think about that for a minute.

So, on the one hand, you have the US distance runners, who run to pick up a bigger running shoe contract; to have themselves featured in a New York Times article, perhaps; to garner the respect of some small fraction of the general public who gives a shit; to achieve a modicum of local fame, and in the process maybe have fewer beer bottles thrown out the windows of trucks at them during their training runs; heck, maybe even to have the other runners give them a second look when they take the starting line at international competitions. Then, on the other hand, you have the Kenyans, who just run to end civil war and save the lives of thousands or even millions of their countrymen.

Suddenly, this country's inferiority on the international distance running scene makes perhaps a bit more sense. Congratulations to Sammy Wanjiru for bringing the first Olympic marathon gold to Kenya--may it provide the profound national impact you and your teammates have dreamed of.

Outside Hospital

One of my co-residents told me about this video, and of course I'm probably seeing it about six months, at least, after the peak of its popularity. But for anyone with any experience working at an academic medical center, this portrayal certainly rings true. Even more interesting on a personal note, the guy playing the CEO of "Outside Hospital" was a friend of mine in medical school: he was the 4th year class president when I was the 1st year class president. He's apparently now an internal medicine attending at U Penn.

A good way to end the week

I'm officially finished with night float. No more nocturnal rotations, ever. My diurnal rhythms will henceforth be afforded the respect they deserve.

As an added bonus, in the past couple of days I've received acceptances from a couple of literary journals: an online flash fiction journal called HeavyGlow, and a print journal called Bellevue Literary Review. I've been trying for a couple of years now to break into BLR, so that's a great feeling. Two acceptances in one week, after nearly a year-long drought! Crazy.

Now, I sleep.

The thrill of victory and the agony of defeat

Sometimes in neurosurgery the greatest technical triumphs coincide with the greatest patient care defeats. That is, often those tasks that require the most manual dexterity or technical proficiency only present themselves because your patient is in a dire situation. I can provide an example from a recent call night. We had a patient come in with a severe subarachnoid hemorrhage. Here's a CT scan:


That whitish stuff towards the center of the picture (worse on the right, which, in the backwards world of radiological imaging, refers to the patient's left) is hemorrhage that's not supposed to be there. The astute interpreter of head CT scans will also note significant cerebral edema, with effacement of the basal cisterns. That is to say that the cisternal spaces around the brainstem, in which cerebrospinal fluid normally circulates freely in a healthy brain, have been compacted by the pressure in the cranium. Not surprisingly, this patient was what we would term moribund; on the five point grading scale of severity of subarachnoid hemorrhage, he was a five. When he arrived in the emergency department he showed practically no sign of neurological function.

However, this patient happened to be quite young--so young, in fact, that we wanted to give him every possible chance at recovery. In this case that included administering a medication, Mannitol, to reduce the intracranial pressure (ICP), as well as hyperventilating him (which also reduces ICP). The next option to entertain for treating high ICP is to drain off some cerebrospinal fluid from the ventricles of the brain. Here's another scan:


This is an image of the patient's brain at the level of the foramen of Monroe. Those two little darker slits towards the center/front of the scan are the lateral ventricles where they come together and drain into the third ventricle through the foramen of Monroe. When we place a ventriculostomy catheter, which is a rubber drain that we slide into the brain for the purposes of draining off spinal fluid, we try to put our catheter in one of the lateral ventricles with the tip right at the forament of Monroe. Normally we do this in patients with hydrocephalus, who have scans that look more like this, with very large ventricles...

...which clearly provide a much easier target than I could shoot for with my patient. Under normal circumstances if we have to put a ventricular catheter in someone with ventricles that small, we use special computer-assisted image guidance to ensure that we can place the catheter appropriately.

My point here is that a ventriculostomy in this particular patient was to be no small task. In fact, it would be the sort of thing that a neurosurgery junior resident could brag about.

So here I am, it's 2:00 am, and I'm dealing with this extraordinarily sick patient who needs a catheter slid into his infinitesimal ventricles. So I run up to the neuro ICU, gather my supplies, and set up for a ventriculostomy. I talk to the family, and explain to their stunned and barely comprehending faces that their loved one is in exceptionally critical condition, and that this procedure, though unlikely to help, is the only thing we can offer that might make any difference to his neurologic outcome (this sort of glum prognostication is par for the course in neurosurgery).

After the family agrees to proceed, I hurry back into the patient's room, which has now collected a handful of interested onlookers. Usually we perform these procedures in our neuro ICU, where the placement of a ventriculostomy hardly garners a shrug, but in the ED its novelty usually attracts an audience of several techs, nurses, and residents.

I act fast, because I know that every second matters for this patient's already poor prognosis. I shave the scalp, mark out my landmarks on the skull, and tape the head to the bed to keep it still. Then I prep the skin and ready my supplies. After placing sterile drapes over the area, my first move is to confirm my landmarks (this is of utmost importance when the ventricles are small), and then slice a 2 cm opening in the scalp. The most nauseating move--for the onlookers, that is, the uninitiated--comes next, which is using a hand-held drill to (quite indelicately) drill a hold through the skull. After puncturing through the inner margin of skull you need to clean up all the errant bone chips, at which time the only thing separating you from the brain is a thick lining of connective tissue called the dura mater. This I puncture open, and now all that's left before I can relax is the passage of my rubber catheter into the slit-like ventricles six centimeters deep.

Any time I advance a catheter into the brain and pull out the stylet, I expect to hit paydirt with the first shot. I have to have that expectation--after all, this is somebody's brain. But sometimes you pull out the stylet and nothing comes out, and you drop the catheter down below the level of the ear to help the fluid flow out and still nothing comes, and you feel this sense of visceral free-fall as if you've just crested the top of a roller coaster and your gut knows you're sinking before your brain does. I hate that feeling. It's guilt and fear and shame and regret all rolled into one. So then you have the pull the catheter back out and reassess everything--your landmarks on the skull, your angle of approach, the size and position of the patient's ventricles--everything. Because you have to get it right the next time.

In this case, it took me a couple of passes to find this patient's very small ventricles. But I found them. Spinal fluid shot out of the catheter tip, with an opening pressure of 45 cm of water (measured according to the height of a fluid column). That's three times the upper limit of normal, and this despite the mannitol and the hyperventilation. That is, as we say in the business, bad.

But I nailed it. Not with the first pass, but I managed to pass a rubber catheter blindly into someone's head and hit a target about the size of a poker chip turned on its side. I should have felt proud. I should have bragged about how I managed to place an impossible ventriculostomy under less-than-perfect circumstances in the middle of the night. I should have printed out the patient's next head CT scan and run proudly around the department with it.

Except the patient didn't survive to have a second head CT scan. The ventriculostomy didn't help. So instead of a victory celebration, I had to explain to the family that their loved one continued, despite our best efforts, to have no sign of neurologic function.

Technical victory. But defeat in every way that matters.

Let the light shine in

Conversation just had:

Wife: "What are you doing?"

Me: "Writing a blog post."

Wife. "Oh. I think I need to open a window in here or something. Something to remind us that we're part of the world."

Me: "What makes you think we're part of the world?"

BACKFIRE

3:55 am. Getting killed. Just grabbed a razor and some cream from supply room and shaved the beard. Back to work.